Sir - In her May 4 news item, Sarah Ramsay*Médecins Sans Frontières, London EC1R 5DJ, UK; and Public Health Policy Unit, London School of Hygiene and Tropical Medicine, London WC4 reports that the Global Fund to Fight AIDS, Tuberculosis, and Malaria falls lamentably short of the US$7-10 billion per year that the UN has estimated is necessary to tackle HIV/AIDS alone.

In the first round of fund disbursement US$380 million were granted to 40 programmes over two years http://www.globalfundatm.org (accessed July 3, 2002). . A substantial portion of these funds will be used to procure drugs, including antiretrovirals.

Although the Fund has made explicit its support for the Doha declaration of October, 2001, on the Trade-Related Intellectual Property Rights (TRIPS) agreement and public health, confusion seems to remain as to acceptable sources of drugs. The application from Malawi stated: "... we are assuming that the Global Fund will only finance patented drugs. This is in line with consultations with WHO and the donor community and initial documents from the Technical Support Secretariat".

As an intergovernmental initiative of substantial influence, it is essential that the Fund promotes policies that encourage equitable and sustainable access to essential medicines. It has the potential to encourage efforts to establish systematic equity pricing and promote access to medicines, including the development of sustainable tiered pricing systems and the use of homeproduced or imported generic products.

It also has the potential to discourage countries from making use of generic products and TRIPS safeguards, and so undermine the intent of the Doha declaration, by effectively subsidising the use of high-priced branded products.

A recent consensus statement from 12 major health non-governmental organisations defines several moves that are required from the Fund if it is to meet its potential in promotion of access to health care in developing countries.

The Fund should publicise its strong support for the Doha declaration, and issue guidelines to help countries make appropriate use of the provisions outlined in the declaration in their proposals. Efforts to introduce legislation to support equity pricing, and the use of the TRIPS safeguards, if relevant, should be supported by the Fund working with relevant intergovernmental organisations.

An explicit commitment should be made to support the provision of quality products by the most affordable and most sustainable means, including systematic equity pricing through tiered pricing systems and the use of generic supplies, accessed where necessary through the issue of voluntary or compulsory licences. This should form part of the criteria by which proposals are considered.

WHO's work on pre-qualification of suppliers of affordable medicines will facilitate the best use of funding and should be supported by the Fund. Furthermore, the Fund should collaborate with intergovernmental bodies in development and use of global or regional bulk purchase mechanisms for these medicines.

The Doha declaration makes clear that the TRIPS agreement should be implemented in a way that ensures the right to protect public health and, in particular, to promote access to medicines for all who need them. Indicators for measurement of the success of the Global Fund should include its role in promotion of the practical application of these rights by national governments.Médecins Sans Frontières, London EC1R 5DJ, UK; and Public Health Policy Unit, London School of Hygiene and Tropical Medicine, London WC4

Tom Ellman, Nathan Ford, Ruairi Brugha